Orthostatic hypotension is a common, treatable cause of falls and is often missed because blood pressure is measured only sitting. Have the patient lie down for five minutes, measure blood pressure and pulse, then stand them up and repeat at one and three minutes.
A fall of 20 mmHg systolic or 10 mmHg diastolic within three minutes confirms it; in a patient with supine hypertension, a systolic fall of 30 mmHg is the usual threshold. A pulse that does not rise suggests autonomic failure. Ask about symptoms during standing, since a reproduction of the patient's dizziness is as useful as the numbers. If positive, review antihypertensives, diuretics, alpha-blockers, nitrates and tricyclics first.
- Measure lying blood pressure after five minutes' rest.
- Repeat standing at one and three minutes.
- A fall of 20 systolic or 10 diastolic confirms orthostatic hypotension.
- Note whether the pulse rises and whether symptoms are reproduced.
- Review blood pressure-lowering and sedating drugs if positive.
Why it matters
A sitting blood pressure cannot detect one of the most treatable causes of falls.
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